Encoderpro.com: for Payers

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Encoderpro.com: for Payers

1,196.761,495.95

EncoderPro.com for Payersprovides online access to comprehensive code validation software for fast search capability. Designed specifically for payer organizations, users can search for CPT® procedures, HCPCS Level II supplies and services, and both ICD-9-CM diagnosis and procedures codes and ICD-10-CM and PCS based on descriptions on the provider and hospital claim forms. Plus, with EncoderPro.com for Payers, users can correctly identify the services in question for outpatient and inpatient hospital services, invasive procedures, CT, MRI, and PET scans.

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Key Features and Benefits

Optum360 CodeLogicTM search engine. Find and validate CPT®, HCPCS, and ICD-9-CM codes using lay terms, acronyms, abbreviations, and even the misspelled words found on outpatient and inpatient UB-04s and providers’ CMS-1500 claim forms.

ICD-10-CM and PCS– Includes mapping content from ICD9 v1v2, and v3 codes to ICD10-CM and PCS codes (as well as backward mapping) using the GEM (General Equivalency Mappings) and Optum360’s MapSelect clinical mapping content. Also includes ICD-10-CM and PCS searching and Optum tabular (ICD10-CM and PCS books) content.

Enhanced compliance editor (includes Optum360’s ClaimsManager rules). Check claim compliance for selected codes through an edit check to ensure proper unbundling, correct modifiers, complete diagnoses, and more prior to submittal to a clearinghouse/vendor/payer. Includes an 24-month historical content database for use during claim adjudication. Over 130 coding rules are reviewed.

Color-coded edits. Determine charges allowed by Medicare for capitation, fee-for-service, outpatient and inpatient hospital services, and provider payments. Know cost and reimbursement amounts by understanding whether a code carries an age or sex edit, is covered by Medicare, or contains bundled services.

Local coverage determinations (LCDs) and Medicare’s Pub. 100 access. Check procedures for Medicare coverage instructions and medical necessity edits across all CMS MACs. Understand which ICD-9-CM (and ICD-10-CM) procedures define medical necessity and what the documentation guidelines are for successful claim submission. Gain insight into procedures and services that carry little or discretionary coverage and how to report them.

Medicare secondary payer coordination of benefits. Access the entire MSP Manual and understand assigning responsibility for first and second payer.